Linda Van Dillen: I have a bachelor’s degree in human resources, and a diploma in nursing (three year program), and am CCM certified. I have been a nurse for 34 years.

What was your first job out of college and how did you get into case management?

I started out in psychiatric nursing and then quickly moved into the emergency department. Within six months I was managing the second shift in the ED. I was working as an occupational nurse and the risk manager at the company I was working at told me about medical case management and said I should give it a try.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

While working for my current company, I designed a case management software program and my late husband did all the programming and we obtained a patent for the software. This program allowed our staff to become paperless and made their jobs overall more efficient and easy.

In brief, describe your organization.

S&H Medical Management Services is an independent, regional, women’s owned medical and vocational case management firm. We are completely virtual! Because we are paperless even our admin team works from home. The quality of life at our organization as a result is phenomenal.

What are two or three important concepts or rules that you follow in case management?

First, I believe in the ethical treatment of all parties involved in the case management process.

Secondly, I work towards an adherence model vs. a compliance model of case management. I strive to ensure all parties have the information they need to make an informed decision.

What is the single most successful thing that your organization is doing now?

We have recently worked to update and upgrade our vocational program. Vocational consultants in each of our territories have become certified ergonomic assessment specialists (CEAS.) Our physical demand analyses are very highly regarded and as a result of this upgrade to our services, we have doubled our vocational team in the past couple years!

Do you see a trend or path that you have to lock onto for 2012?

We have done research into the top cost trends in workers’ compensation and as a result have modified our services to assist the claims staff in making informed decisions as to reserving the claims and making recommendations to mitigate these costs.

What is the most satisfying thing about being a case manager?

Ensuring a win-win opportunity for all parties. When the injured worker obtains excellent, goal-directed care they return to work (RTW) in a more timely and effective manner. In this society we need to work, and facilitating a successful RTW ensures a good ongoing quality of life for the worker.

What is the greatest challenge of case management, and how are you working to overcome this challenge?

I think case management, especially in the workers’ compensation industry, are many times still viewed as a necessary evil or a drain on the bottom line. S&H is constantly striving to ensure goal-directed quality care, timely RTW and documentation of the cost savings achieved as a result of the case manager’s intervention.

What is the single most effective workflow, process, tool or form case managers are using today?

At S&H I believe our proprietary software for case management documentation has made our staff more effective. S&H has also adapted the CMSA adherence tools and we utilize these tools to assist with adherence assessments.

Where did you grow up?

I am a St. Louis native. If you are from St. Louis you ask what high school you attended. That would be Riverview Gardens in north county.

What college did you attend? Is there a moment from that time that stands out?

I started out in college to become a home economics teacher (glad I didn’t stick with that – are there home ec teachers anymore?) After nursing school, I attended Webster University to obtain a degree in human resources. When in nursing school I remember one of my teachers telling me I should go into an area of nursing without a fast pace as at first I struggled with starting IVs, etc. This just made me more determined and one of the reasons I applied to work in the ED. I was one of the first people certified in advanced cardiovascular life support (ACLS) in the St. Louis area and became an instructor.

Are you married? Do you have children?

Currently I am widowed, but just recently remarried on June 1st. I have two children, both girls. My oldest daughter is a nun in Alabama and my youngest daughter has a degree in computers but is currently enrolled in nursing school.l

What is your favorite hobby and how did it develop in your life?

Biking. After my husband passed away I decided to take control of my health so my girls didn’t lose both parents. I lost 120 pounds through diet and exercise. I ran a half marathon at age 56!

Is there a book you recently read or movie you saw that you would recommend?

I recently read the Hunger Games trilogy and saw movie #1. It was very interesting on so many levels. It made me think of how you can use power for good or for evil, and even when you are supposedly the “good guy” your actions can be used to either truly help others or to just promote your viewpoint.

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Don’t rely on technology, and don’t expect busy doctors to take on added administrative tasks. Those are just two lessons that have shaped Florida Blue’s programs to improve the quality of primary care over the last eight years.

And while Florida Blue’s name may be new, its mandate to identify and close critical gaps in patient care is longstanding.

The organization formerly known as Blue Cross Blue Shield of Florida (Florida BCBS) has had a quality-focused program to recognize excellence in primary care since 2004, explained Barbara Haasis, RN, CCRN, Florida Blue’s senior clinical lead, quality reward and recognition programs in a recent webinar on The Patient-Centered Medical Home: Lessons from a Statewide Rollout.

In 2004, Florida BCBS rolled out Recognizing Physician Excellence (RPE), its first statewide pay-for-performance (PFP) quality program for more 4,000 primary care physicians.

Seven years later, when the Florida payor decided results from the RPE program had topped out, it shifted direction to a patient-centered medical home (PCMH) approach, which reflected both industry trends and requests from employer groups.

In parallel with RPE, it piloted its PCMH program with a small number of practices in 2010, focusing on patients with diabetes and hypertension. The practices in the pilot were offered a registry to record patient data, but the expectation that electronic health record (EHR) data could be dropped into the registry was not met. Neither were busy physicians willing to complete the patient information forms themselves.

Based on lessons learned in the pilot, Florida Blue opted not to require any type of e-connectivity or EHR when it rolled out the program statewide in 2011, aligning instead with the e-connectivity standards of national programs such as the NCQA medical home recognition program.

However, mandates to utilize e-prescribing and to provide at least six hours of after-hours coverage are included in the program’s eligibility requirements.

Today there are more than 1,800 physicians in the program covering 25 counties; well over half a million Florida Blue members see a physician participating in the PCMH.

Florida Blue issues quarterly scorecards to its PCMH physicians that contain the results of their quality metrics in six key ares as well as feedback on their total cost of care. Overall, Florida Blue finds that physicians participating in the medical home program are more efficient in their total cost of care and have better quality outcomes than those who have never participated in a quality program before.

Nurse educators and medical field directors from Florida Blue support the physicians in the delivery of patient-centered care. Ms. Haasis said Florida Blue will also add four practice transformation coordinators to assist practices in the transition to the medical home model of care.

In what is believed to be the largest accountable care program in New Hampshire, the Granite Health Network (GHN) and Cigna are launching a collaborative accountable care initiative to expand patient access to healthcare, improve care coordination, and chip away at escalating healthcare spend associated with high risk, high utilization patients.

To benefit from this collaboration are more than 23,000 individuals covered by a Cigna health plan who receive care from more than 900 healthcare professionals across GHN’s five independent charitable healthcare organizations. Patients who need help managing a chronic condition such as diabetes or heart disease will be among the first to reap the new program’s benefits.

Critical to the program’s benefits are registered nurses, employed by each of the five GHN healthcare organizations, who serve as clinical care coordinators and are integrated into the care delivery team to help patients with chronic conditions or other health challenges navigate their healthcare system. The care coordinators will enhance care by using patient-specific data provided by Cigna to identify patients being discharged from the hospital who might be at risk for readmission, as well as patients who may be overdue for important health screenings or who may have skipped a prescription refill. The care coordinators will contact these individuals to help them get the follow-up care or screenings they need, identify any issues related to medications and help prevent chronic conditions from worsening.

The care coordinators will also help patients schedule appointments, provide health education and refer patients to Cigna’s clinical programs, such as disease management programs for diabetes, heart disease and other conditions; and lifestyle management programs, such as programs for tobacco cessation, weight management and stress management. This initiative is unique in using data and analytics at the health system level to focus healthcare professionals more fully on engaging patients to improve the coordination of their care as well as develop best practice clinical initiatives across the GHN member health systems.

Cigna will compensate GHN for medical and care coordination services it provides. Additionally, GHN organizations may be eligible for financial incentives if they meet specified clinical and financial targets, Cigna said.

What does it take to be a Nurse Navigator for Bon Secours Medical Group? Just ask Irene Zolorotofe, RN, MS, MSN, who recruits, hires and trains nurse case managers to work alongside healthcare providers in the medical practices.

New nursing graduates need not apply; instead, Bon Secours has tapped its community network of experienced nurse case managers and also recruited via the positive publicity generated by this program.

A newly hired Nurse Navigator is teamed with a veteran to learn the ropes, which include a 12-session training program in chronic disease management as well as an introduction to the tools and resources that support Bon Secours case management efforts. Their six-week orientation includes training on home visits, chronic disease registries used to identify “hot-spotters;” evidence-based guidelines, and phone scripts to follow during patient outreach.

Bon Secours trainers take a “deep dive” into medication adherence, emphasizing the importance of engaging a patient in this aspect of self-care. However, the most important job of an embedded Nurse Navigator is building a relationship with the care team and providers with which he or she is working, says Ms. Zolorotofe.

Nurse Navigators are currently co-located at 10 Bon Secours sites; priorities are internal medicine and cardiology. In certain cases, a Nurse Navigator may be shared among several practices. And sometimes due to sheer patient volume, a virtual case manager is needed to back up Bon Secours embedded Nurse Navigator.

The intensive training of Bon Secours Nurse Navigators in risk assessment and management of chronic disease is reaping dividends for the organization, with especially impressive results in diabetes management. Some practices hold a “Diabetes Day” on which all patients with this diagnosis are brought in for relevant eye exams, foot exams, and inoculations. There are also group visits to teach this population about diabetes self-management, complications, diet, and medication.

Experience has taught Bon Secours that the Nurse Navigators are best utilized in the practices and not in hospitals. “Sending Nurse Navigators into the hospital not efficient,” Ms. Zolorotofe noted. “We now work with the hospitals’ inpatient case managers to watch hospitalized patients from a distance.”

It’s not new that obesity numbers are going up. Hardly a week goes by that we don’t report an alarming new statistic on this problem; the latest, from Duke University, states that nearly half of the U.S. population could be obese by 2030; and 11 percent of this group will be severely obese, or roughly 100 pounds or more overweight.

It’s hardly new that obesity endangers not just its victims, but our healthcare infrastructure as well; a recent study from Duke and the AHRQ reported that obesity costs states $15 billion a year in medical expenses, and the Institute of Medicine (IOM) estimates that obesity costs the United States $190.2 billion a year in health-related costs. And the costs of obesity aren’t limited to our country; according to new data from the World Health Organization (WHO), “In every region of the world, obesity doubled between 1980 and 2008,” says Dr Ties Boerma, Director of the Department of Health Statistics and Information Systems at WHO. “Today, half a billion people (12% of the world’s population) are considered obese.” The report goes on to say:

The highest obesity levels are in the WHO Region of the Americas (26% of adults) and the lowest in the WHO South-East Asia Region (3% obese). In all parts of the world, women are more likely to be obese than men, and thus at greater risk of diabetes, cardiovascular disease and some cancers.

So it’s by no means new that efforts are once again underway to control this epidemic, with the IOM’s new report on “Accelerating Progress in Obesity Prevention.” But what is new is the scope of the conversation on obesity this time. Just this month, Kaiser Permanente, HBO, the National Institutes of Health, the Michael & Susan Dell Foundation, the CDC and the IOM launched a major public-health campaign aimed at obesity, excess weight and their effects on the nation’s health. A new four-part documentary series from HBO, called the Weight of the Nation, is currently available to all cable subscribers, not just HBO subscribers. And the CDC held a Weight of the Nation conference in Washington, D.C. on May 7th, where speakers stressed that while knowledge of healthy eating and lifestyle strategies were widely known, access to these strategies weren’t always easily accessible.

And just about every media outlet has made the issue a pivotal part of their program. Because according to the IOM’s report, it will take a concerted effort from all to make any progress.

In its comprehensive review of obesity prevention-related recommendations, strategies and action steps that have the greatest potential to speed up progress in combating the obesity crisis, the agency presents five goals:

Make physical activity an integral and routine part of life.

Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice.

Transform messages about physical activity and nutrition.

Expand the roles of healthcare providers, insurers, employers.

Make schools a national focal point.

There must be consensus among all relevant parties to help make these goals attainable, the report stresses. To make physical activity more accessible, one example encourages civic leaders to convert unused spaces, like railroad beds, into walking/running/biking trails. To make healthy food and beverage options available, the report recommends the following steps:

reducing unhealthy food and beverage options while substantially increasing access to healhier food and beverages at competitive prices. The overconsumption of sugar-sweetened beverages must be reduced; calories substantially slashed in meals served to children while the number of affordable, healthier menu options is boosted significantly; and governments need to provide incentives to encourage supermarkets and other food retailers to place stores in underserved areas.

Congress, the White House, federal policy makers and foundations have to dedicate funds to develop and implement sutstained social marketing campaigns aimed at physical activity and nutrition. Employers and doctors need to encourage and uphold better health. And schools need to be a major advocate of healthy eating for children, because most children spend nearly half their days there, and according to the IOM, consume between one-third to one-half of their daily calories there.

Maybe this is just what we need, an APB, of sorts, or a call to action to everyone from individuals to families to schools to doctors to employers to civic leaders to the White House to get on board with this issue. Because none of this is new information. But just maybe, we could make it old news.

Under a proposed rule, Medicaid will reimburse primary care services for family medicine, general internal medicine, pediatric medicine and related sub-specialists at Medicare levels in 2013 and 2014. Such a ruling could help encourage primary care physicians to continue and expand their services to Medicaid beneficiaries, including providing checkups, preventive screenings, vaccines and other care, CMS officials say.

CMS follows the AMA’s recommendations when calculating physicians’ fees under Medicare nearly 90 percent of the time, a report from Columbia University finds. The fees, which are based on assessments of time and effort associated with various physician services, often influence how some state and private payors pay doctors. In recent years there have been increasing pay gaps between PCPs and specialists, and PCPS have expressed concerns that the AMA committee is partly responsible for this. More in this issue.

The problem of obesity continues to grow, with the latest findings estimating that nearly half of the U.S. population could be obese by 2030, which means the healthcare system could be burdened with 32 million more obese people by that time, according to research from Duke University, RTI International, and the CDC. Keeping obesity rates level could save nearly $550 billion in medical expenditures over the next two decades, researchers state.

And the age of claimants for critical illness insurance policies decreased in the past year, according to a study from the American Association for Critical Illness Insurance. The majority of claimants were younger than 55, marking a significant increase in claims by younger policyholders compared to those filed in 2010.

Don’t forget to participate in our second annual survey on ACOs. If you contribute by May 16th, you will get a FREE executive summary of the compiled results and year-over-year ACO trends.

Hillary Calderon: I have been a director of case management for over 16 years. I worked for (now Vanguard-owned) Baptist Hospital in San Antonio for nine years, and then transitioned to an HCA-owned facility in San Antonio, Northeast Methodist Hospital. I am an RN, working on my master’s degree.

What was your first job out of college and how did you get into case management?

I actually was working as a unit secretary (as my degree was in home economics). I then went to nursing school and worked as a telenurse for five years. The case management department was in its infancy and I helped bring it to fruition. We went through many changes; it was a good opportunity and I wanted to be challenged to start a new restructuring in the field.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

Well, many. Making a difference for patients and now making a difference with case managers that are making a difference. I am thankful that I have the opportunity to assist case management departments in creating a process that will meet corporate and CMS requirements. It seems like when I question my way, it comes back as the correct road for me to be on. I love this, so it is not work for me!

In brief, describe your organization.

HCA- Hospital Corporation of America. We currently have over 170 hospitals (and growing) across the nation. Great company to work for!

What are two or three important concepts or rules that you follow in case management?

Keep focused on your goals. The goals should be patient and family first. Right plan for the patient/family.

Remember what is in scope for you to do. Do what you can, concentrate on that. Don’t get caught up in “extra” duties as assigned, unless it pertains to your goal (see first item)

What is the single most successful thing that your organization is doing now?

Focusing on initiatives, quality driven and clinical excellence.

Do you see a trend or path that you have to lock onto for 2012?

Care coordination. A must for healthcare to achieve better outcomes and cost containments.

What is the most satisfying thing about being a case manager?

The knowledge base, the liaison role that a case manager has in communicating with the patient, family, administration, payors and post-acute providers. Problem solving, it’s like a puzzle!

Where did you grow up?

Grew up in Dallas (early years), then San Antonio the rest of my years.

What college did you attend? Is there a moment from that time that stands out?

East Texas State University… no not really a moment in time. I was a member of the Gamma Phi Beta Sorority. Loved that!

Are you married? Do you have children?

Married, three daughters… 21, 25, and 28. No grandkids, and they are all three single!

What is your favorite hobby and how did it develop in your life?

I love, love, love gardening. I have always loved the outdoors and creating landscapes. I also love to paint (watercolor and acrylic).

Is there a book you recently read or movie you saw that you would recommend?

Last book I read was “The Help.” I am last at reading the trends. I am in the process of reading “The Hunger Games.” Last movie I saw was “The Artist,” this year’s Oscar winner. Loved it!

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Obesity and diabetes continue to make headlines, and are the subjects of two of our stories this week. The first: the United States has among the highest rates of obesity and diabetes-related deaths than most nations, according to researchers contributing to a new Commonwealth Fund report. This, among other factors, accounts for the United States’ spending more on healthcare than most nations, but getting just fair marks when it comes to quality. More on this, including the nation with the lowest per capita healthcare costs, in this issue.

Kaiser Permanente, HBO, and four major organizations are hoping to raise the country’s rating with a new public health campaign aimed at obesity, excess weight and their effects on the nation’s health. Integral to the campaign is the launch of The Weight of the Nation, a four-part documentary series that will be available to all cable subscribers, not just HBO subscribers, on May 14th and 15th. There will also be an option to view the series with Spanish subtitles. Along with HBO, Kaiser is working with National Institutes of Health, the Institute of Medicine, the Michael & Susan Dell Foundation and the CDC on this month-long campaign.

A campaign of a different sort takes aim at underserved communities, with the government’s continued effort to ensure their access to primary healthcare services. HHS has dedicated nearly $730 million to build, expand or improve community health centers. Currently, more than 8,500 service delivery sites around the country deliver care to more than 20 million patients regardless of their ability to pay.

And there are no likely measures on tap to rein in specialty drug spending, which is expected to soar over the next decade, according to a new study from the Center for Studying Health System Change (HSC). Unlike conventional prescription drugs, whose spending has been limited by patent expiration, generic substitution and other factors, health insurers and employers have few tools to control rapidly rising spending on specialty drugs, which are typically high-cost biologic medications used to treat complex medical conditions. Studies show that specialty drug spending has increased by 14 to 20 percent annually in recent years.

Regardless of whether the Supreme Court overhauls health reform, the industry is seriously thinking about ways to cut healthcare spending, either by reexamining the need for commonly administered services or unraveling the mysteries of medical bills.

As we reported in a recent news story here, a coalition of nine leading physician specialty societies representing nearly 375,000 physicians have identified specific tests or procedures that they say are commonly used but not always necessary in their respective fields.

Coordinated by ABIM Foundation’s Choosing Wisely campaign, the lists of “Five Things Physicians and Patients Should Question” provide specific, evidence-based recommendations physicians and patients should discuss when making healthcare decisions. Among the tests that patients might not necessarily need are stress imaging tests for annual checkups if the patient is an otherwise healthy adult without cardiac symptoms, according to the American College of Cardiology, and chest X-rays for patients going into outpatient surgery, according to the American College of Radiology. Most of the time, the x-ray images will not result in a change in management and have not been shown to improve patient outcomes, college officials say.

A recent opinion piece from the New York Times echoes the feeling that more evaluation of health services and costs is necessary, and sheds some light on the abundance of medical tests. The article, Why Medical Bills are a Mystery, written by Robert S. Kaplan and Michael E. Porter, professors of accounting and strategy, respectively, at Harvard Business School, states that:

The lack of cost and outcome information also prevents the forces of competition from working: Hospitals and doctors are reimbursed for performing lots of procedures and tests regardless of whether they are necessary to make their patients get better. Providers who excel and achieve better outcomes with fewer visits, procedures and complications are penalized by being paid less.

The article goes on to cite a lack of uniformity for healthcare costs and reimbursements, and suggests that by analyzing costs, hospitals can save money and improve care:

Because health care charges and reimbursements have become disconnected from actual costs, some procedures are reimbursed very generously, while others are priced below their actual cost or not reimbursed at all. This leads many providers to expand into well-reimbursed procedures, like knee and hip replacements or high-end imaging, producing huge excess capacity for these at the same time that shortages persist in poorly reimbursed but critical services like primary and preventive care.

The study looked at nearly 20,000 cases of routine appendicitis at 289 hospitals and medical centers throughout California. The patients – all adults – were admitted for three or fewer days. The researchers uncovered an enormous discrepancy in what different hospitals charge, ranging from a low of $1,529 to a high of nearly $183,000. The median hospital charge was $33,611. The startling cost variation reveals a “broken system,” the authors said.

“Consumers should have a reasonable idea of how much their medical care will cost, but both they and their healthcare providers are often unaware of the costs,” said lead author Renee Y. Hsia, MD, an assistant professor of emergency medicine at UCSF.

What to do? The Journal of the American Medical Association (JAMA) weighed in on ways to cut waste and improve quality in U.S. healthcare. In a recent article researchers identified six categories where cuts could result in a significant reduction in healthcare costs. In these six categories: overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse, the sum of the lowest available estimates exceed 20 percent of total healthcare expenditures.

Now that Facebook users can post their organ donor status as easily as photos of last night’s dinner, it might be time for healthcare to “like” social media a little more.

Starting today, Facebook users can indicate in their timeline that they’re an organ donor. They can also share stories about their decision to become a donor and register for state and national organ donor registries.

Facebook’s move reflects the increasing integration of social media and health behaviors. Consumers, especially 18- to 24-year-olds, are heavily invested in social media use for health-related matters  for education, provider and treatment reviews, physician interactions, and decision-making, according to new research by the Health Research Institute (HRI) at PricewaterhouseCoopers (PwC).

The report found that social media activity by hospitals, health insurers and pharmaceutical companies is miniscule compared to the activity on community sites such as patientslikeme&#174, where 146,438 members (today’s count at 1:56 pm EDT) share thoughts on more than 1,000 medical conditions.

For example, the report notes that while eight in 10 healthcare companies (as tracked by HRI during a sample one-week period) had a presence on various social media sites, community sites had 24 times more social media activity than corporate sites.

For the uninitiated, the idea of social media can be intimidating. There are also legitimate concerns related to patient confidentiality and privacy. To this end, the General Medical Council (GMC) has drafted guidance for doctors on managing the risks of using social media Web sites such as Twitter and Facebook to connect with patients. Rule number 1: maintain a professional boundary between doctor and patient.

Still not convinced? If Facebook’s organ donation tool doesn’t motivate, here are five more trends in health-related use of social media identified in the HRI research:

One-third of consumers now use social media sites such as Facebook, Twitter, YouTube and online forums for health-related matters, including seeking medical information, tracking and sharing symptoms, and broadcasting how they feel about doctors, drugs, treatments, medical devices and health plans.

Four in 10 consumers say they have used social media to find health-related consumer reviews (e.g. of treatments or physicians); one in three have sought information related to other patients’ experiences with their disease; one in four have “posted” about their health experience; and one in five have joined a health forum or community.

When asked how information found through social media would affect their health decisions, 45 percent of consumers said it would affect their decision to get a second opinion; 41 percent said it would affect their choice of a specific doctor, hospital or medical facility; 34 percent said it would affect their decision about taking a certain medication; and 32 percent said it would affect their choice of a health insurance plan.

While 72 percent of consumers said they would appreciate assistance in scheduling doctor appointments through social media channels, nearly half said they would expect a response within a few hours.

Young adults are leading the social media healthcare charge. More than 80 percent of individuals between the ages of 18 and 24 said they were likely to share health information through social media channels and nearly 90 percent said they would trust information they found there. By comparison, less than half (45 percent) of individuals between the ages of 45 and 64 said they were likely to share health information via social media.

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